Dr. John Miklos and Dr. Robert Moore – Vaginal Mesh Complication Surgeons

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Mesh Complication Case Study #20

Avaulta Mesh Complication - Vaginal and Buttock Pain

Initial Mesh Surgery:  Total Vaginal Mesh Procedure (Avaulta- Bard Urology), Total Vaginal Hysterectomy

Post Mesh Surgery Symptoms:  Severe vaginal and buttock pain, Pain w/ intercourse for 3 years

Surgery to Repair Mesh Complications:  Vaginal mesh removal, Pudendal nerve release

Patient is a 37 year old who had surgery by her general gynecologist for cystocele and rectocele 3 years ago.  She had a vaginal hysterectomy and Avaulta Mesh Repair for cystocele and rectocele. Her original surgery included:

• TVH (total vaginal hysterectomy)
• Avaulta Anterior and Posterior Mesh Procedure

Mesh Complication Symptoms

Vaginal, Buttock, and Leg Pain: Immediately after surgery, the patient woke up with severe vaginal pain, buttock and leg pain. The pain was more than should be expected after surgery and it did not improve, as it should over the first 4 to 6 weeks.  She had vaginal pain and pulling with movement and sitting.  She had severe left buttock pain and she could not sit or stand for any period of time without the pain worsening and/or shooting down the back of her leg.

Severe Pain with Intercourse: After the initial healing course of 6-12 weeks, the pain improved slightly, however she continued to have many of the same symptoms of above.  She was seen by her surgeon and was told that everything "looked great" and the result was "excellent." She inquired about the pain however was told it was normal and it would improve.  She did attempt intercourse after cleared by her surgeon, however she could not engage in intercourse secondary to severe pain.  She tried several times over the next few months but the pain did not improve, nor could she engage in intercourse.  She went to see her surgeon who again told her there was nothing wrong and that she should “go home and have sex every night for 6 weeks and that will take care of the pain."  She did try this and again, it did not work because she could not tolerate intercourse without severe pain.

She continued living with this pain for several years as she saw multiple surgeons, however all told her that there was nothing wrong, nor could anything be done.  Her marriage was struggling because of it, and she was getting very depressed.

Treatment - The patient came in to see Dr. Moore and Miklos and was found to have good vaginal support and normal length.  On the surface and initial exam, everything did appear normal, however on more extensive examination the anterior arms of the Avaulta when palpated caused severe pain.  Additionally, the posterior arms of the Avaulta were also very tight and when the left was palpated via rectal examination, this reproduced the severe pain on the left side.  This arm both created a Pudendal Nerve injury or neuropathy and needed to be released and removed away from the nerve.

Dr. Moore and Miklos took her to surgery and removed the entire anterior and posterior wall meshes, releases all arms and tension on the sidewall muscles and removed the arm from the Left sacrospinous ligament. They also released the scar tissue and the mesh arm away from the pudendal nerve on the left.

Comment by Dr. Moore - If there are signs of a pudendal neuropathy on either side, this can be caused by one of the mesh arms that is placed through the sacrospinous ligament.  The nerve can be injured during placement or it can be placed too tight or heal under tension which can create pulling or scar tissue irritating the nerve.  In these cases it usually is not enough to just release the arm.  It typically needs to be removed completely out of the ligament and the scar tissue released away from the nerve.  This is a very difficult procedure and should only be completed by an expert. The first generation kits that utilize a needle pass through the buttock cheeks (such as Prolift or Avaulta) and pass the arm blindly through the back of the ligament are at risk for this type of complication.)

Outcome - The patient recovered well and although she still has some pain, the pain down the back of her leg and in her buttock cheek has resolved, the pulling pain in her vagina resolved and she is undergoing pelvic floor physical therapy and has a good outlook to be able to have pain free intercourse in the future.

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